Application for Employment
{We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion or
national origin.}
PERSONAL INFORMATION: Date:
Name: Last First Middle (Initial)
Present Address: __ Street City State Zip
Phone Number: ( ) Social Security Number: ______________
Referred by: Date of Birth: _________________________
EMPLOYMENT DESIRED:
Position: Date you can start: __ Salary desired: ________________
Are you Employed Now? May we contact your current employer? _____________________________________
Have you ever applied at this company before? Where? ______________ When? ____________________
EDUCATION:
NAME OF SCHOOL |
LAST YEAR COMPLETED |
DID YOU GRADUATE? |
SUBJECTS STUDIED |
HIGH SCHOOL:
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{circle one} 9 10 11 12 |
YES NO |
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COLLEGE:
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{circle one} 1 2 3 4 5 6 |
YES NO |
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Special Skills:
Activities:
(e.g. Civic, Athletic, Etc.)
(Continued on Other Side)
FORMER EMPLOYERS: List below the last four employers. ( Start with last one first.)
DATES EMPLOYED |
NAME AND ADDRESS OF PAST EMPLOYERS |
SALARY |
POSITION |
REASON FOR LEAVING |
From: To: |
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REFERENCES: Give below the names of three persons not related to you, whom you have known at least one year.
NAME |
COMPANY NAME |
PHONE NUMBER |
NO OF YEARS |
1. |
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2. |
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3. |
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PHYSICAL RECORD: Do you have any physical condition which may limit your ability to perform the job applied for?
(This question is voluntary, and any answers will be kept confidential.)
IN CASE OF EMERGENCY, PLEASE CONTACT: NAME PHONE NUMBER
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.
NAME DATE
DO NOT WRITE BELOW THIS LINE
INTERVIEWED BY:
REMARKS:
HIRED: Y / N For Dept: Position: Will Report: / / Salary: _____________
Approved: